Organization Active NPI

Concordia Support Services, LLC

Community/Behavioral Health Agency
Fayetteville, NC

National Provider Identifier

1417045188

Registry record updated Jun 25, 2009

On this page

Key facts
NPPES NPI Registry
National Provider Directory
NPI Registry JSON
Other providers in Fayetteville, NC
Sources for this page

Key facts

NPPES NPI Registry

Primary specialty: Community/Behavioral Health AgencyTaxonomy code 251S00000X
Legal business name: CONCORDIA SUPPORT SERVICES, LLC
Practice address: 2315 Bloom Avenue
Suite 2
Fayetteville, NC 28304-6165
Phone: (910) 826-8253
Fax: (910) 826-8254
NPI assigned: Oct 10, 2006
Organization subpart: No

NPPES NPI Registry

Updated by the provider on Jun 25, 2009

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name: Meredith Nickelberry
Title: Vice President
Phone: (910) 826-8253

Specialties & licenses 6

Specialty (taxonomy)	Code	License	State	Primary
Developmentally Disabled Services Day Training Agency	251C00000X
Community/Behavioral Health Agency	251S00000X			Primary
Intellectual and/or Developmental Disabilities Residential Treatment Facility	320600000X	MHL-067-156	NC
Intellectual and/or Developmental Disabilities Residential Treatment Facility	320600000X	MHL-067154	NC
Intellectual and/or Developmental Disabilities Residential Treatment Facility	320600000X	MHL-047-070	NC
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	320900000X

Addresses

Primary practice location

2315 Bloom Avenue
Suite 2
Fayetteville, NC 28304-6165

Mailing address

PO Box 26108
Fayetteville, NC 28314-5018
Phone (910) 826-8253

Other identifiers 18

Identifier	Type	State
8300606	Medicaid	NC
8301129G	Medicaid	NC
6603837	Medicaid	NC
8300606B	Medicaid	NC
8300606G	Medicaid	NC
6006251	Medicaid	NC
6603570	Medicaid	NC
8300604	Medicaid	NC
8300605B	Medicaid	NC
8301129H	Medicaid	NC
6603687	Medicaid	NC
8300605	Medicaid	NC
5950244	Medicaid	NC
8301864B	Medicaid	NC
83001129B	Medicaid	NC
8300604B	Medicaid	NC
8301129	Medicaid	NC
8301864	Medicaid	NC

National Provider Directory

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160438400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1245888000000",
    "number": "1417045188",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 26108",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283145018",
            "telephone_number": "910-826-8253",
            "fax_number": "910-826-8254"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2315 BLOOM AVENUE",
            "address_2": "SUITE 2",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283046165",
            "telephone_number": "910-826-8253",
            "fax_number": "910-826-8254"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CONCORDIA SUPPORT SERVICES, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-10",
        "last_updated": "2009-06-25",
        "status": "A",
        "authorized_official_last_name": "NICKELBERRY",
        "authorized_official_first_name": "MEREDITH",
        "authorized_official_title_or_position": "VICE PRESIDENT",
        "authorized_official_telephone_number": "910-826-8253"
    },
    "taxonomies": [
        {
            "code": "251C00000X",
            "taxonomy_group": "",
            "desc": "Day Training, Developmentally Disabled Services",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "251S00000X",
            "taxonomy_group": "",
            "desc": "Community/Behavioral Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "NC",
            "license": "MHL-067-156",
            "primary": false
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "NC",
            "license": "MHL-067154",
            "primary": false
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "NC",
            "license": "MHL-047-070",
            "primary": false
        },
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300606",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8301129G",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603837",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300606B",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300606G",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6006251",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603570",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300604",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300605B",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8301129H",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "6603687",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300605",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5950244",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8301864B",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "83001129B",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8300604B",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8301129",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8301864",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fayetteville, NC

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 25, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.